Vol. 17 •Issue 8 • Page 21
There’s No One-Size Fits All Mode in Home Care Industry
Because they are continually tailoring their care to the needs of each patient, RTs working for home care companies rarely see one clear-cut trend in the home care industry. And since such care is provided behind closed doors in countless communities nationwide, very few other people can see definite trends emerging in the industry either.
As a result, generalities offered about the average home care patient often miss the mark because views are based on limited contact with a limited population. In this hidden world, the care given to Patient A may not mirror care given Patient B, even though both patients have the same disease. Again, this is caused because no individuals are alike in need and progression of disease.
Statisticians would probably be equally hard pressed to give a median age of home care patients or even predominant gender of patients.
But if one generalization could safely be made about home care patients, it would probably be the stereotypical patient is receiving oxygen therapy to ease COPD-induced inflammation.
At least, that’s what one veteran therapist said is true in his area. An estimated 80 percent of patients receiving home care at HomeLife Oxygen LLC in Memphis, Tenn., are COPDers, said owner Greg Foust, BS, RRT. Most of them are getting supplemental oxygen.
LIFE SENTENCE
Once COPDers go on oxygen, they most likely will rely on it for the rest of their lives. To give a median time the patients need oxygen in a home care setting is not an easy task, Foust added. “I would say the average is two to three years. But we’ve had several do well for four and five years and sometimes longer.”
The longest Foust has worked with a patient with COPD was for a little more than seven years. That was an ex-Marine who took to the oxygen well. The veteran Marine, who died six months ago, didn’t require hospitalization during those seven years of home care.
But occasionally Home Life will get referrals from pulmonologists to treat patients with atypical lung diseases like fibrosis or interstitial pneumonia.
Although these pa.tients are few and far between, if they turn up at the doorsteps of durable medical equipment suppliers, their length of care usually does not last longer than six months, Foust said.
Which patients will get oxygen at home and for how long is left entirely at the discretion of the pulmonologist. “The physicians decide, based on pulmonary function studies in the office and pulse oximetry tests, if the patient has recovered enough to wean off the oxygen,” Foust explained. Follow-up tests of the patient’s arterial blood oxygen saturation determine whether or not the patient’s lungs can function without the supplemental oxygen.
PAYMENT PLANS
If laboratory evidence shows the patients need oxygen, the Centers for Medicare and Medicaid Services (CMS) will cover 80 percent of the cost of home oxygen therapy, explained Joan Kohorst, MA, RRT, regional clinical manager at Apria Healthcare. The patient’s secondary medical insurance covers the remaining 20 percent or the patients pay the remainder of the cost.
There are no uniform rules for third-party payers. Their policies are internal. “Some private insurers follow the strict CMS guidelines for coverage, but most of them require only a prescription from the patient’s physician,” Kohorst said.
Generally, guidelines for oxygen prescription require: a lab result showing the patient has an arterial PO2 less than or equal to 55 mm Hg or an arterial oxygen saturation (SaO2) less than or equal to 88 percent at rest. However, there are exceptions to that rule.
For example, oxygen therapy may be covered if the patient’s SaO2 is no more than 90 percent and PO2 is no more than 60 mm Hg, provided the patient concurrently has any one of the following conditions: dependent edema suggesting congestive heart failure, pulmonary hypertension determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” wave changes on an ECG, or erythocythemia with a hematocrit less than 56 percent.
When ordering the oxygen therapy, physicians must specify the estimated length of need and the oxygen liter flow. Under the CMS guidelines, patients get re-evaluated and re-tested, according to the following schedule:
• Patients who were initially prescribed oxygen for less than a “lifetime” get re-evaluated within 90 days prior to the end of the first month of the therapy and must be re-tested within 30 days prior to the end of the first 12 months of therapy.
• Patients who were prescribed oxygen for “lifetime” get re-evaluated within 90 days prior to the end of their first 12 months of therapy.
• Group II patients (the ones with the concurrent disorders) require re-testing of their oxygen levels between 61 and 90 days of oxygen therapy.
LOGISTICAL NIGHTMARE
But should that sat. number alone determine whether or not to continue oxygen use? Foust said he heard an interesting caveat to this issue at last year’s American College of Chest Physicians conference during a session led by Thomas L. Petty, MD, professor of medicine and chairman of the medical department at the University of Colorado in Denver.
It is not always the best decision to discontinue oxygen for COPD patients whose saturations have improved, Petty told audience members.
If the saturation levels are healthy and above 88, physicians shouldn’t immediately discontinue the oxygen, according to the physician. The improved number only means that the therapy is working, and discontinuing could reverse three months of care.
Discontinuing oxygen therapy before the patient can fully benefit can transform the patient’s health into a logistical nightmare and turn their care into a vicious circle, Foust noted. Most likely if these patients are taken off the oxygen, they will end up in the hospital again, then back on oxygen through home care.
You can reach Stacey Miller at [email protected].
